Dr. Gary D. Kao

Dale and I once interviewed Ezra Klein about health care on our podcast. Klein held the VA system up as a shining example of good government health care. Of course that was before the shameful condition of Walter Reed had been discovered. Since then other problems (for instance, contaminated colonoscopy equipment in various locations) have been discovered.

A commenter once asked “if VA is good enough for our veterans, why isn’t it good enough for us.” My answer was “it isn’t good enough for our veterans, it is instead what they’re stuck with.”

Today brings another example of the problems this sort of medicine is bound to have. It is a bureaucratic nightmare, even at the relatively small size of VA.

For patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans’ hospital in Philadelphia, his aim was more than a little off.

Most of the seeds, 40 in all, landed in the patient’s healthy bladder, not the prostate.

It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.

He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.

The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.

That as they say, was the tip of the iceberg. No one reported the problem because there was no peer review. And, this was one of many mistakes made by this doctor that apparently no one knew about:

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.

The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.

Six years and no one had a clue. In fact, if you read the article in full, as you should, you’ll see that the discovery of this was essentially an accident.

This is government health care. This is what our vets are stuck with. This is not something we, as a society, should want any part of.